Failure to Complete Quarterly Care Plan Reviews
Penalty
Summary
The facility failed to revise care plans for residents on a quarterly basis as required. During a review of medical records and staff interviews, it was found that one resident had only a single care plan documented, which was created at the time of admission. There was no evidence in the medical record that the care plan had been reviewed or revised by the interdisciplinary team (IDT) after the initial development, despite the resident having been admitted for a period that would require at least one quarterly review. The Regional Director of Social Services confirmed during an interview that care plans are supposed to be reviewed every 90 days and acknowledged that the resident in question should have had at least one care plan revision since admission. The facility's process involves using an electronic medical record system to track care plan review tasks, but in this case, the system did not indicate that a review was due, and no subsequent care plan reviews were documented for the resident.